Doctor, Computer, Patient

Nearly anyone who has visited a doctor over the past five years will have noticed the intrusion of a very unwelcome guest into the clinic room: the laptop computer. Instead of looking at you as she asks about your painful joints or soul-sucking depression, the doctor’s eyes are locked on the screen, her fingers busily clicking away on the Chiclet keyboard. You feel as if you have only half her attention, and as if the questions she asks come not from the doctor’s own well of human concern, but from a menu of keyboard options. The therapeutic dyad—the special relationship between doctor and patient—has slowly evolved into a rather uncomfortable triad: doctor-computer-patient (with computer wedged firmly in the middle, like a small child demanding everyone’s attention).

It isn’t only patients who despair over the computerization of the doctor-patient encounter; many doctors hate the intrusion, too. “You can’t imagine,” one doctor I talked to said, “how hard it is to try to talk to a patient while you are also trying to type, and then trying to fix the typos that you’ve made because you are in a hurry, and having to navigate a EMR (electronic medical records) interface that doesn’t necessarily give you the prompts that you need.” You lose so much, he said, when you are taking a history using the computer. You miss a lot of information that is passed nonverbally, though posture or facial expression or vocal inflection. You don’t follow your own intuitive train of thought in asking diagnostic questions, because there are electronic prompts. You are looking down at the keyboard, not into the patient’s face, and thus cannot effectively express his own feelings of concern and empathy with what the patient is saying. "The computer is supposed to enhance what we do; instead, it gets in the way of helping patients."

Doctors haven’t had much choice. My husband’s small family practice clinic is a good example of what’s happened and why computers have become so ubiquitous. His practice has worked incredibly hard over the past few years to accommodate the changes in health care and improve how they do things. They have, of course, switched to electronic medical records from the now prehistoric paper filing system. They have instituted government-mandated changes to help collect and track data, and can now identify groups of high-risk patients such as diabetics who need regular follow-up. They have been certified as a level 3 Patient-Centered Medical Home. All of this is part of a push to improve the quality of care they provide, while also trying to remain financially viable as a small practice in an increasingly big-system and competitive market. Yet many of the changes my husband and his partners have been encouraged (sometimes forced) to implement, in order to provide excellence in care, have also pushed them more firmly into the use of computers in patient rooms. This may have improved some aspects of care, but it has also made the job of being a doctor more difficult. These days, my husband often comes home looking exhausted and strung-out.

With all the technological gains, something important is being lost. We know from piles of research, as well as from plain old common sense, that one of the most important things about the healing work of doctors lies in the doctor-patient interaction itself—indeed, this why placebos are so effective. So, in the evolution of health care toward increasing use of computers, we are losing far more than just the undivided attention of our doctor; we are losing some of the healing power of medicine. We are losing (both metaphorically and practically) the laying on of hands, the gentle probing of painful spots, both physical and emotional.

My husband came home from work a few nights ago and announced: “I did something today that made the entire day feel better: I left my laptop out of the room.” It wasn't easy--he had to figure out creative ways to get the information into the computer after the patient visit, with no time to spare. But it worked. This one simple act of rebellion against the new regime made his experiences with his patients better. He felt more present, more engaged, and less stressed out. Once again, he understood why he used to love being a doctor—a love that has been sorely challenged the past few years.